Who Decides Whether Trump Is Unfit to Govern?

The mental health of Donald Trump has been under scrutiny since he began running for president. Now 28 Democratic Congress members have signed on to a bill, introduced in April, that could lead to a formal evaluation of his fitness.

The bill seeks to set in motion a part of the 25th Amendment that empowers Congress to establish a body to assess the president’s ability to govern. The commission created by the bill would have 11 members, at least eight of whom would be doctors, including four psychiatrists. If the commission doctors found Mr. Trump unfit to govern and the vice president agreed, the vice president would become acting president. Since the 25th Amendment was written to address temporary disability, it allows the president to announce that he has recovered — presumably Mr. Trump would do so immediately — and force a congressional vote on the finding of unfitness.

The role of psychiatry in this process would be problematic. One of us is a lifelong Democrat, the other a Republican (if an increasingly ambivalent one). But as psychiatrists and citizens, we agree on this point: The medical profession and democracy would be ill served if a political determination at this level were ever disguised as clinical judgment.

Much has been written lately about the Goldwater Rule, the American Psychiatric Association’s prohibition against members’ evaluating anyone they have not personally examined. The rule dates to 1973, when analysis of patients’ unconscious processes drove diagnosis. Today, diagnosis is often linked to observable traits, making evaluation at a distance plausible. Even if Mr. Trump refused to cooperate, diagnosis might be the easy part — perhaps too easy. Whether or not they can say so, many experts believe that Mr. Trump has a narcissistic personality disorder. He is grandiose, entitled, desperate for admiration and so on.

But any number of presidents have remained in office despite some level of mental impairment. Historians believe that Abraham Lincoln, for example, had clinical depression. A president can have a mental disorder and, overall, function admirably. In the absence of disability, a president may be inexperienced, indecisive or inept. Psychiatrists would be alarmed if mental illness were considered an absolute bar to public service.

The 25th Amendment is imprecise, but clearly the intent is to cover impairment arising from illness. Once an impairment is diagnosed, doctors on the panel would need to determine whether the president is incapacitated and whether the incapacity results from the disorder. For grave conditions like psychotic episodes, severe dementia or massive strokes, the connection is easy. But what of less automatically disqualifying ailments?

The traits that might earn Mr. Trump a diagnosis of personality disorder were on display during the election campaign. His supporters judged that egotism was compatible with leadership. He is governing as he campaigned. He is impulsive, erratic, belligerent and vengeful.

But is Mr. Trump unfit to govern in the meaning of the 25th Amendment? If so, its provisions might have been invoked the day he took office. If not, when did the incapacity arise? Would the commission monitor a president’s behaviors, judging which is the last straw?

In practical if perhaps not in moral terms, these decisions might be less troubling if Mr. Trump were found, say, to have Alzheimer’s disease, with a resultant coarsening of longstanding personality traits. To the extent that the president’s supporters accepted expert opinion, they might be less resistant to the removal of a demented commander in chief than a narcissistic one.

But considering personality disorder only: How does it relate to fitness? Can erratic behavior be strategic? Decisions at this level of refinement become ever less scientific, less medical.

However flawed, the Goldwater Rule saves psychiatrists from the temptation to misuse diagnosis for partisan purposes. The establishment of a standing oversight commission reintroduces this concern, in spades. Assuming that doctors confirmed that Mr. Trump was egotistic, would they then declare him unfit based on established patterns of conduct — on Trump being Trump?

That result would strike those who elected him as elitist and anti-democratic. Don’t the people have the right to choose an exceedingly narcissistic leader?

For a president who is unfit but not impeachable and who still has the support of his cabinet, the Constitution offers Congress only this one way out, a declaration of impairment presented by a deliberative body of its choice. But that body need not be dominated by doctors. Senator Birch Bayh, the Indiana Democrat who drafted the 25th Amendment, which was ratified in 1967, specifically opposed relying on physicians to make what he considered a political determination.

If the time comes that Congress finds Mr. Trump unable to discharge his duties, its members should appoint a bipartisan commission dominated by respected statesmen to set the removal process in motion. Obviously, if a president’s health deteriorates drastically, medical consultants should be called in. But when the problem is longstanding personality traits, a doctor-dominated commission simply provides cover for Congress — allowing legislators, presumably including those in the majority, to arrange for the replacement of the president while minimizing their responsibility for doing so.

Peter D. Kramer is an emeritus professor of psychiatry at Brown. Sally L. Satel is a psychiatrist and resident scholar at the American Enterprise Institute.